V03-05 ROBOTIC APPENDICEAL ONLAY URETEROPLASTY FOR RECURRENT LOW GRADE UROTHELIAL CARCINOMA

Abstract

INTRODUCTION AND OBJECTIVE: We report the case of a 63 year-old male smoker with recurrent low grade urothelial carcinoma and papillary urothelial neoplasm of low malignant potential, refractory to multiple rounds of endoscopic management. He underwent successful robotic assisted mid-ureteral segmentectomy followed by augmented ureteroplasty with anterior onlay appendiceal flap. METHODS: After docking, the right ureter was mobilized and direct visual ureteroscopy helped delineate the margins of the tumor using precise suture ligation to sequester the tumorous segment. After specimen removal, the defect was assessed and residual tension due to retraction precluded a suitable primary ureteroureterostomy (UU). After consideration of the various reconstructive options, we decided upon an appendiceal interposition. The appendix had adequate length, and intravenous indocyanine green (ICG) with near-infrared fluoroscopy (NIF) showed good blood supply. Appendix amputation followed by cecopexy to the psoas muscle was performed to reduce pedicle tension. The proximal appendix was unexpectedly found to be obliterated and the plan was revised to perform an augmented ureteroplasty with appendiceal onlay flap. A double-J ureteral stent was placed, followed by the completion of the onlay. RESULTS: Estimated blood loss was minimal (100cc); console time was 219 minutes. There were no complications. The patient was discharged on post-operative day 1. Follow-up retrograde pyelogram showed prompt drainage of contrast and a patent ureter and the stent was removed 10 weeks after the surgery. CONCLUSIONS: The appendix can serve as a suitable ureteral substitution in situations unamenable to UU, given the need for additional length. A skilled reconstructive urologist needs to maintain a high level of intraoperative flexibility in the event that original plans change based on anatomic findings during the case. Additionally, adjuncts such as intraoperative ureteroscopy and the use of ICG/NIF can prove significantly useful during complex reconstructive cases. Source of Funding: None